- Manasije Mishra Dhanush, 31 years old engineer with a multinational company, had bought a health insurance policy in 2008. He was happy paying the premium for the confidence it brought him, knowing that the medical need of his family would be fulfilled without any hassle. A month back, Dhanush got admitted into a private hospital for hernia surgery confident that it would be approved for cashless claim as this was the first time he was using his health insurance policy. To his surprise, it got declined by the TPA. He was shocked and called his insurer for clarity. Dhanush was then informed that the cashless claim is applicable only for network hospitals.
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All insurers provide the option of cashless hospitalization to the customers. While selecting a policy, it should be an important consideration as it may get difficult for the customer to assess the available options during an unforeseen medical emergency. Had Dhanush read his policy terms and conditions carefully or opted for an insurer with personalized customer service to explain the step by step procedure to avail cashless claims, it would have been helpful in this situation.The reality unfolds only at the time of hospitalization, where the patient walks into a hospital and is told that either the cashless facility is not applicable to that particular hospital, or the procedure not covered, or else, the limits approved are low. Talking to your insurer to understand the product as well as the terms and conditions at the time of policy purchase is critical.
It is crucial to file the claims appropriately as per the policy documents. It is therefore beneficial for the customers to understand what makes for the cashless hospitalization, how to go about it and what is covered and not covered under the policy for cashless claims.
3 steps to cashless claim:
Step 1: Select and approach the customer service of the insurer or the TPA helpdesk stationed at the network hospital. It is recommended to submit the request at least 72 hours before the treatment. In case of a planned hospitalization, it needs to be pre-authorised by the insurer. For identification purposes, use Passport, Voters' Card, PAN Card or Driver's Licence along with your health card provided by the insurer or the policy number. Max Bupa customers can check the list of network hospitals from the company website, Facebook page or by simply calling on the customer service number.
Step 2: Network hospital would check the identity for validation and submit pre-authorization form to the insurer. Max Bupa provides decision to the hospital within 4 hours, when no further document is required. In case of planned hospitalization it is advisable to file for the request as soon as the doctor advises hospitalization.
Step 3: Get admitted for treatment and sign all documents, forms and invoices on dischargeIn case of an emergency, a customer is only required to give the network hospital the cashless treatment card number.
Key imperatives to be kept in mind:• Cashless claim services are available only at network hospitals• Documents including, medical bills, lab reports, claim forms and discharge papers (duly signed by the treating doctor) need to be submitted to the hospital before dischargeo Maintain a copy of the above documents for future reference• Read the policy documents carefully before signing. Cashless claims have a large number of conditions that could restrict from availing of the facilityo If the illness is not covered under the policyo If you have exhausted your sum assured sum for that policy periodo If the pre-authorization form has been filled incompletely What is not covered under a cashless claim policy?• Visitor’s fees• Registration fees• Cost of medicine like adult diapers, oxygen masks and nebulisers etc.• Document charges• Diet charges• Toiletries
Generally, an insurer will accept to pay only part of the sum required for the treatment of the patient, and settles the final bill with the hospital after the patient has been treated. In some cases if the policy holder exceeds the policy sum assured limit, then the policy holder will be required to pay the excess amount. It is true that knowledge is power. Therefore, it is advisable to read the policy documents carefully to avoid unexpected last minute rejection of cashless claim.
(The writer is CEO, Max Bupa Health Insurance)
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